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Wang D, Chen Y, Ji F, Hu JW, Zhou PH, Xu SC, Chen Y, Ye LP, Ye GL, Li R, Li ZS. Hybrid argon plasma coagulation for the treatment of Barrett’s esophagus: A prospective, multicenter study. World J Clin Cases 2024; 12:3866-3872. [DOI: 10.12998/wjcc.v12.i19.3866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 05/09/2024] [Accepted: 05/20/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND The incidence of Barrett’s esophagus (BE) in China is lower compared to the Western populations. Hence, studies conducted in the Chinese population has been limited. The current treatment options available for BE treatment includes argon plasma coagulation (APC), radiofrequency ablation and cryoablation, all with varying degrees of success.
AIM To determine the efficacy and safety of HybridAPC in the treatment of BE.
METHODS The study cohort consisted of patients with BE who underwent HybridAPC ablation treatment. These procedures were performed by seven endoscopists from different tertiary hospitals. The duration of the procedure, curative rate, complications and recurrent rate by 1-year follow-up were recorded.
RESULTS Eighty individuals were enrolled for treatment from July 2017 to June 2020, comprising of 39 males and 41 females with a median age of 54 years (range, 30 to 83 years). The technical success rate of HybridAPC was 100% and the overall curative rate was 98.15%. No severe complications occurred during the operation. BE cases were classified as short-segment BE and long-segment BE. Patients with short-segment BE were all considered cured without complications. Thirty-six patients completed the one-year follow-up without recurrence. Twenty-four percent had mild dysplasia which were all resolved with one post-procedural treatment. The mean duration of the procedure was 10.94 ± 6.52 min.
CONCLUSION Treatment of BE with HybridAPC was found to be a simple and quick procedure that is safe and effective during the short-term follow-up, especially in cases of short-segment BE. This technique could be considered as a feasible alternative ablation therapy for BE.
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Affiliation(s)
- Dong Wang
- Department of Gastroenterology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Yan Chen
- Department of Gastroenterology, Changhai Hospital, Shanghai 200438, China
| | - Feng Ji
- Department of Gastroenterology, The First Affiliated Hospital Zhejiang University School of Medicine, Hangzhou 311399, Zhejiang Province, China
| | - Jian-Wei Hu
- Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Ping-Hong Zhou
- Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Shu-Chang Xu
- Endoscopy Center, Tongji Hospital of Tongji University, Shanghai 200092, China
| | - Ying Chen
- Endoscopy Center, Tongji Hospital of Tongji University, Shanghai 200092, China
| | - Li-Ping Ye
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province, Taizhou 318001, Zhejiang Province, China
| | - Guo-Liang Ye
- Department of Gastroenterology, The Affiliated Hospital of Medicine School, Ningbo University, Ningbo 315021, Zhejiang Province, China
| | - Rui Li
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Shanghai 200438, China
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Mueller J, Kayser G, Kuellmer A, Schiemer M, Bettinger D, Offensperger F, Thimme R, Schmidt A. ArgoCap - feasibility and safety of a novel over-the-scope device to facilitate endoscopic APC treatment. MINIM INVASIV THER 2023:1-9. [PMID: 36825622 DOI: 10.1080/13645706.2023.2180322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
INTRODUCTION Argon plasma coagulation (APC) is an electrosurgical procedure used, among other indications, for treatment of dysplastic Barrett's mucosa. Homogeneous and safe application can be compromised by varying distances and suboptimal angle of the probe to the tissue. In this study, we present ArgoCap, a novel endoscopic device developed to facilitate endoluminal APC treatment. Objectives of this preclinical study were to assess feasibility and safety and to determine suitable APC settings. MATERIAL AND METHODS One-hundred and thirty-two APC treatments of predefined areas using various APC settings were performed ex vivo in the opened porcine esophagus. Depth of thermal injury was assessed histologically. Feasibility of APC treatment in different locations was examined in 20 explanted porcine esophagi and in first in vivo porcine applications. RESULTS APC treatment in all quadrants of the esophagus was feasible. Histologically, thermal effects involving the whole thickness of the mucosa were visible with all settings. APC with pulsed mode resulted in deep thermal damage with all power settings. No lesions of the muscular layer occurred using precise (E8, E9) and forced (10 W, 20 W) mode. CONCLUSIONS Esophageal APC using ArgoCap is feasible and safe. The device has the potential to improve APC treatment of larger mucosal areas.
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Affiliation(s)
- Julius Mueller
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Gian Kayser
- Department of Pathology, University of Freiburg, Freiburg, Germany
| | - Armin Kuellmer
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Moritz Schiemer
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Florian Offensperger
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
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Bai Y, Yang F, Liu C, Li DF, Wang S, Lin R, Ding Z, Meng WB, Li ZS, Linghu EQ. Expert consensus on the clinical application of high-frequency electrosurgery in digestive endoscopy (2020, Shanghai). J Dig Dis 2022; 23:2-12. [PMID: 34953023 DOI: 10.1111/1751-2980.13074] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/20/2021] [Indexed: 12/11/2022]
Abstract
High-frequency electrosurgery has been widely applied in digestive endoscopy with constantly expanding indications. However, high-frequency electrosurgery may cause possible complications such as hemorrhage or perforation during or after the procedure, of which endoscopists must be cautious. Digestive endoscopists must have a firm grasp of the principles of high-frequency electrosurgery as well as its safety issues so as to improve the safety of its clinical application. To this end, experts in gastroenterology and hepatology, digestive endoscopy, surgery, nursing and other related fields were invited to draft a consensus on the clinical application of high-frequency electrosurgery in digestive endoscopy based on relevant domestic and international literatures and their experiences.
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Affiliation(s)
- Yu Bai
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Fan Yang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Cui Liu
- Digestive Endoscopy Center, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - De Feng Li
- Department of Gastroenterology, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, Shenzhen, Guangdong Province, China
| | - Shi Wang
- Endoscopy Center, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, Zhejiang Province, China
| | - Rong Lin
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Zhen Ding
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Wen Bo Meng
- Department of General Surgery, First Hospital of Lanzhou University, Lanzhou, Gansu Province, China
| | - Zhao Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - En Qiang Linghu
- Department of Gastroenterology and Hepatology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
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4
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Maselli R, Belletrutti PJ, Spadaccini M, Galteri PA, Stäbler T, Ederer M, Neugebauer A, Enderle MD, Repici A. Fluid cushion protects against thermal damage during argon plasma coagulation. Ann Gastroenterol 2021; 34:845-851. [PMID: 34815651 PMCID: PMC8596213 DOI: 10.20524/aog.2021.0667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 06/16/2021] [Indexed: 12/04/2022] Open
Abstract
Background Thermal damage to the muscle layer during mucosal application of argon plasma coagulation (APC) may be avoided by creating a fluid cushion within the submucosal layer, but the minimum injection volume needed or the ideal injection fluid are yet to be established. We conducted a systematic ex vivo study with this aim. Methods All experiments were performed in an ex vivo porcine gastrointestinal tract model. Five different fluids (saline, Glyceol, Gelafundin, Voluven, and Eleview) of different volumes were injected into the submucosa of different parts of the gastrointestinal tract. APC was applied to the mucosa at different power settings. Immediately after APC treatment, the temperature was measured through a thermocouple placed inside the fluid cushion, just on top of the muscle layer. The minimum volume of fluid needed to protect the muscle layer from thermal damage was determined. Results There was no difference in the temperature measured among the different injection fluids at the surface of the muscle, in all the locations, at equal injection volumes and power settings. The minimum amounts of fluid needed to protect the muscle layer were 2 and 3 mL for power settings of 30-90 W and 90-120 W, respectively. Conclusions Normal saline and 4 commercially available submucosal injection fluids possess similar thermal protective effects. To reduce the likelihood of thermal damage to deeper layers when APC is applied, a minimum injection volume of 3 mL is recommended if less than 90 W power will be utilized over 3 sec.
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Affiliation(s)
- Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy (Roberta Maselli, Marco Spadaccini, Alessandro Repici).,Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy (Roberta Maselli, Paul J. Belletrutti, Marco Spadaccini, Piera Alessia Galteri, Alessandro Repici)
| | - Paul J Belletrutti
- Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy (Roberta Maselli, Paul J. Belletrutti, Marco Spadaccini, Piera Alessia Galteri, Alessandro Repici)
| | - Marco Spadaccini
- Department of Biomedical Sciences, Humanitas University, Milan, Italy (Roberta Maselli, Marco Spadaccini, Alessandro Repici).,Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy (Roberta Maselli, Paul J. Belletrutti, Marco Spadaccini, Piera Alessia Galteri, Alessandro Repici)
| | - Piera Alessia Galteri
- Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy (Roberta Maselli, Paul J. Belletrutti, Marco Spadaccini, Piera Alessia Galteri, Alessandro Repici)
| | - Thomas Stäbler
- Research Department Erbe Elektromedizin GmbH, Tubingen, Germany (Thomas Stäbler, Michael Ederer, Alexander Neugebauer, Markus D. Enderle)
| | - Michael Ederer
- Research Department Erbe Elektromedizin GmbH, Tubingen, Germany (Thomas Stäbler, Michael Ederer, Alexander Neugebauer, Markus D. Enderle)
| | - Alexander Neugebauer
- Research Department Erbe Elektromedizin GmbH, Tubingen, Germany (Thomas Stäbler, Michael Ederer, Alexander Neugebauer, Markus D. Enderle)
| | - Markus D Enderle
- Research Department Erbe Elektromedizin GmbH, Tubingen, Germany (Thomas Stäbler, Michael Ederer, Alexander Neugebauer, Markus D. Enderle)
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Milan, Italy (Roberta Maselli, Marco Spadaccini, Alessandro Repici).,Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy (Roberta Maselli, Paul J. Belletrutti, Marco Spadaccini, Piera Alessia Galteri, Alessandro Repici)
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Itani MI, Oberbach A, Salimian KJ, Enderle M, Hahn H, Abbarh S, Kendrick K, Schlichting N, Anders RA, Besharati S, Farha J, Fayad L, Kalloo AN, Badurdeen D, Kumbhari V. Gastric Mucosal Devitalization (GMD): Using the Porcine Model to Develop a Novel Endoscopic Bariatric Approach. Obes Surg 2021; 32:381-390. [PMID: 34797503 DOI: 10.1007/s11695-021-05773-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 10/10/2021] [Accepted: 11/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS As the pig model has similar gastrointestinal anatomy and physiology to humans, we used pigs to create a gastric mucosal devitalization (GMD) model in preparation for clinical translation of this technique as an endoscopic bariatric therapy (EBT). The aims of this study were to determine the ablation parameters and technique for a successful, safe, and feasible large surface area GMD that produces weight loss. METHODS We performed GMD using argon plasma coagulation (APC) in 3 phases. Phase 1 assessed the ablation energy required to accomplish selective mucosal ablation using ex vivo pig stomachs (n = 2). Phase 2 assessed the optimal percentage of mucosal surface area to be treated and was performed on 10 pigs. Phase 3 assessed feasibility, efficacy, and safety with 8 pigs randomized into GMD (n = 4) or sham (SH, n = 4) and survived for 1 month. Body weights (GMD, n = 4, SH, n = 4) were measured daily in phase 3 for 1 month, and relative body weights were calculated and analyzed using one-tailed Student's t-test. Percent body fat was compared between GMD and SH at baseline and 1 month post-GMD. RESULTS Phase 1 identified the optimal ablation parameters (120 W) that were then used in phase 2. Phase 2 revealed a trend that was suggestive that the optimal percent surface area to ablate was similar to that which is removed at laparoscopic sleeve gastrectomy. In phase 3, GMD was performed over 70% surface area of the greater curvature of the stomach in four pigs. GMD pigs had significantly lower relative body weight increase compared to SH at 1 month (1.375 ± 0.085 vs 1.575 ± 0.047, p = 0.0435). MRI showed a significantly lower body fat mass at 1 month in GMD pigs (5.9 ± 0.4% vs 12.7 ± 2.3%, p = 0.026) compared to SH. CONCLUSIONS GMD resulted in decreased weight gain in the GMD group as evidenced by a lower relative body weight at 1 month. GMD in an animal model appears to show promise as a potential weight loss therapy.
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Affiliation(s)
- Mohamad I Itani
- Department of Internal Medicine, Wayne State University, Detroit, MI, 48201, USA.,Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Andreas Oberbach
- Department of Diagnostics, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Kevan J Salimian
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | | | | | - Shahem Abbarh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Katherine Kendrick
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Nadine Schlichting
- Department of Diagnostics, Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Robert A Anders
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Sepideh Besharati
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Jad Farha
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Lea Fayad
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Anthony N Kalloo
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Dilhana Badurdeen
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, 21287, USA. .,Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Jacksonville, FL, 32224, USA.
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6
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Condon A, Muthusamy VR. The evolution of endoscopic therapy for Barrett's esophagus. Ther Adv Gastrointest Endosc 2021; 14:26317745211051834. [PMID: 34708204 PMCID: PMC8543722 DOI: 10.1177/26317745211051834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/21/2021] [Indexed: 12/20/2022] Open
Abstract
Barrett’s esophagus is the condition in which a metaplastic columnar epithelium
replaces the stratified squamous epithelium that normally lines the distal
esophagus. The condition develops as a consequence of chronic gastroesophageal
reflux disease and predisposes the patient to the development of esophageal
adenocarcinoma. The diagnosis and management of Barrett’s esophagus have
undergone dramatic changes over the years and continue to evolve today.
Endoscopic eradication therapy has revolutionized the management of dysplastic
Barrett’s esophagus and early esophageal adenocarcinoma by significantly
reducing the morbidity and mortality associated with the prior gold standard of
therapy, esophagectomy. The purpose of this review is to highlight current
principles in the management and endoscopic treatment of this disease.
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Affiliation(s)
- Ashwinee Condon
- Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - V Raman Muthusamy
- Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, UCLA, 200 UCLA Medical Plaza, Room 330-37, Los Angeles, CA 90095, USA
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Staudenmann DA, Skacel EP, Tsoutsman T, Kaffes AJ, Saxena P. Safety and long-term efficacy of hybrid-argon plasma coagulation for the treatment of Barrett's esophagus: An Australian pilot study (with video). INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021. [DOI: 10.18528/ijgii200050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | - Tatiana Tsoutsman
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
- The University of Sydney School of Medicine, Sydney, Australia
| | - Arthur John Kaffes
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
- The University of Sydney School of Medicine, Sydney, Australia
| | - Payal Saxena
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
- The University of Sydney School of Medicine, Sydney, Australia
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8
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Estifan E, Cavanagh Y, Grossman MA. Hybrid Argon Plasma Coagulation for Treatment of Gastric Intestinal Metaplasia. Cureus 2020; 12:e7427. [PMID: 32337147 PMCID: PMC7182158 DOI: 10.7759/cureus.7427] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Hybrid argon plasma coagulation (HybridAPC® [HAPC]) is an evolution of the standard argon plasma coagulation (APC) technology, where the application of APC is preceded by high-pressure needleless submucosal injection. APC is indicated for the ablation of benign and dysplastic mucosal lesions, such as vascular malformations or Barrett's mucosa. HAPC offers safety and efficacy advantages over standard APC because the submucosal injection acts as a heat sink that disperses energy. This ensures that the underlying muscularis propria remains unaffected, and only the mucosal layer is coagulated in its entirety. An 81-year-old Hispanic male was found to have a 1.2-cm mucosal nodule along the incisura of the stomach. Pathology of the biopsy specimen revealed high-grade dysplasia, and he subsequently underwent endoscopic ultrasound examination, which confirmed the presence of an isolated gastric nodule with no deep invasion of the muscularis propria, consistent with a uT1N0Mx endosonographic staging. He then underwent endoscopic submucosal dissection of the lesion. Pathology of the excised specimen confirmed the presence of multifocal high-grade dysplasia, arising in the background of extensive intestinal metaplasia. The deep margin was clear; however, the lateral resection margins showed focal involvement of intestinal metaplasia with low-grade dysplasia. Surveillance endoscopy confirmed the persistence of diffuse intestinal metaplasia. He was then treated with widespread HAPC due to the presence of underlying diffuse intestinal metaplasia in the stomach. HAPC is an effective and efficient treatment modality for mucosal lesions. In one series of 50 patients, 96% achieved complete macroscopic remission of Barrett's mucosa after a median of 3.5 APC sessions, and 85% achieved complete histological remission. HAPC is a promising therapeutic modality as a thermal injury is targeted, and the depth of injury is contained. This provides immediate procedural efficacy and safety benefits, and reduces subsequent complications when compared with standard APC. We anticipate that the applications of HAPC will continue to grow, as this modality is adopted into common procedural parlance. This case appears to be the first to describe the use of HAPC for definitive treatment of diffuse intestinal metaplasia.
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Affiliation(s)
- Elias Estifan
- Internal Medicine, St. Joseph's University Medical Center, Paterson, USA
| | - Yana Cavanagh
- Interventional Gastroenterology, St. Joseph's University Medical Center, Paterson, USA
| | - Matthew A Grossman
- Interventional Gastroenterology, St. Joseph's University Medical Center, Paterson, USA
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9
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Fayad L, Oberbach A, Schweitzer M, Askin F, Voltaggio L, Larman T, Enderle M, Hahn H, Khashab MA, Kalloo AN, Kumbhari V. Gastric mucosal devitalization (GMD): translation to a novel endoscopic metabolic therapy. Endosc Int Open 2019; 7:E1640-E1645. [PMID: 31788546 PMCID: PMC6877422 DOI: 10.1055/a-0957-3067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/27/2019] [Indexed: 01/08/2023] Open
Abstract
Background and study aims The metabolic effects of bariatric surgery may partially result from removal of the gastric mucosa, an often underappreciated endocrine organ. Using argon plasma coagulation (APC), we may be able to selectively devitalize (ablate) the mucosa. The aim of this study was to identify the optimal tissue color that would correspond to selective gastric mucosal devitalization (GMD) using ex-vivo human stomach specimens. Patients and methods Stomach specimens were obtained at sleeve gastrectomy. Prior to APC application, a submucosal fluid cushion was created. APC was then applied over a 2 × 2-cm area to the fundus and body, aiming for the three indicator colors (white, golden, brown). Pathological analysis was then performed independently and in a blinded fashion by two pathologists to determine the depth of mucosal and submucosal percent thermal injury and mucosal percent cell death. Results Six patients were enrolled. There was a significant correlation between tissue color and mucosal percent thermal injury. The highest percent mucosal thermal injury was seen with brown (99.6 %, 95 % CI: 98.7, 100), followed by golden (92.5 %, 95 % CI: 85.5, 99.5), and then white (75.2 %, 95 % CI: 58.3, 92.1, P < 0.01). Submucosal thermal injury was seen in 88.9 % of the slides. Greater than minimal submucosal injury (> 10 % depth) was found significantly more with brown tissue color (91.6 %) than golden (75 %) or white (33.3 %, P < 0.05). However, 91.7 % of the entire sample set < 50 % injury. Conclusion GMD is achievable using APC without thermal injury to muscularis propria. A golden color results in sufficient mucosal injury with only superficial injury to the submucosa.
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Affiliation(s)
- Lea Fayad
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Andreas Oberbach
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States,Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | | | - Frederic Askin
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | | | - Tatianna Larman
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | | | | | - Mouen A. Khashab
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Anthony N. Kalloo
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Vivek Kumbhari
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States,Corresponding author Vivek Kumbhari, Associate Professor of Medicine Division of Gastroenterology and HepatologyDirector of Bariatric EndoscopyJohns Hopkins Medical InstitutionsSheikh Zayed Building1800 Orleans Street, Suite 7125GBaltimore, MD 21287
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10
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Arteriovenous malformations respond poorly to argon plasma coagulation in patients with continuous flow left ventricular assist devices. Eur J Gastroenterol Hepatol 2019; 31:792-798. [PMID: 31150365 DOI: 10.1097/meg.0000000000001427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Gastrointestinal bleeding in patients with continuous flow left ventricular assist devices (LVADs) causes significant morbidity. Arteriovenous malformations (AVMs) cause 30-60% of bleeds, yet the efficacy of endoscopic interventions and risk factors for rebleeding have not been studied. PATIENTS AND METHODS The charts of all LVAD patients undergoing endoscopy for gastrointestinal bleeding at Stanford between January 2010 and December 2017 were reviewed. Cox proportional hazard modeling was used to evaluate risk factors for rebleeding, including the type of endoscopic treatment, patient characteristics, and endoscopic findings. RESULTS Of 54 total LVAD patients presenting with gastrointestinal bleeding, 23 (42.6%) had AVMs documented on endoscopy. Treatment with argon plasma coagulation (APC) alone was associated with a higher risk of rebleeding compared to no treatment [hazard ratio (HR)=4.77, P=0.012], and compared with clip±APC (HR=7.47, P=0.012). The 90-day bleed-free rate was 10.9% with APC, 100% with clipping±APC, and 83.3% with no endoscopic treatment. Additional risk factors for rebleeding included the presence of gastric AVMs (HR=3.64, P=0.024), and presence of hematochezia (HR=5.15, P=0.05). In a multiple Cox regression model, only the presence of gastric AVMs (HR=5.50, P=0.029) and APC use (HR=14.3, P=0.008) remained significant predictors of rebleeding. CONCLUSION The use of APC alone for the treatment of AVMs in LVAD patients had a high failure rate. The presence of gastric AVMs was a significant risk factor for rebleeding in LVAD patients. Management decisions should take these factors into account.
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Gastric mucosal devitalization is safe and effective in reducing body weight and visceral adiposity in a porcine model. Gastrointest Endosc 2018; 88:175-184.e1. [PMID: 29476845 DOI: 10.1016/j.gie.2018.02.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 02/11/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The early improvement in metabolic profile after sleeve gastrectomy (SG) indicates that the significant benefits of metabolic surgery are gastric in origin. We have previously demonstrated that devitalization of the gastric mucosa (without a reduction in gastric volume) in metabolically disturbed obese rats results in an improvement of obesity and its associated comorbidities. The aims of this study were to assess the technical feasibility, efficacy, and safety of gastric mucosal devitalization (GMD) in a large animal (porcine) model. METHODS A 3-arm (GMD versus SG versus sham [SH]) prospective randomized controlled trial with an 8-week follow-up period was performed. The primary endpoint was relative weight loss. Secondary endpoints were absolute body weight, abdominal visceral adiposity, abdominal subcutaneous adiposity, organ lipid content, and serum ghrelin level. RESULTS GMD resulted in a significant relative weight loss of 36% over SH at 8 weeks (P < .05). There was no significant difference in relative weight loss between GMD and SG at 4 weeks; however, SG resulted in a 29% superior relative weight loss at 8 weeks (P < .05). With regard to visceral adiposity, there was a significant benefit of GMD over SH at 8 weeks. Despite differences in relative weight loss, there was no significant difference in visceral adiposity between SG and GMD at 8 weeks. Significant improvements in GMD over SH were noted with regard to skeletal and heart muscle lipid content. GMD pigs at 8 weeks demonstrated regeneration of the gastric mucosa without ulceration or significant scarring. Despite mucosal regeneration, the abundance of serum ghrelin was significantly lower in the GMD cohort compared with the SG and SH cohorts. CONCLUSIONS GMD was technically feasible and resulted in relative weight loss and an improvement in visceral adiposity. The benefits noted were out of proportion to what would be expected with weight loss alone.
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Manner H, May A, Kouti I, Pech O, Vieth M, Ell C. Efficacy and safety of Hybrid-APC for the ablation of Barrett's esophagus. Surg Endosc 2015; 30:1364-70. [PMID: 26104794 DOI: 10.1007/s00464-015-4336-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 05/04/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND STUDY AIM After thermal ablation of Barrett's esophagus (BE), stricture formation is reported in 5 to over 10% of patients. The question arises whether submucosal fluid injection prior to ablation may lower the risk of stricture formation. The aim of the present study was to evaluate the efficacy and safety of the new technique of Hybrid-APC which combines submucosal injection with APC. PATIENTS AND METHODS Patients who had a residual BE segment of at least 1 cm after endoscopic resection of early Barrett's neoplasia underwent thermal ablation of BE by Hybrid-APC. Prior to thermal ablation, submucosal injection of sodium chloride 0.9% was carried out using a flexible water-jet probe (Erbejet 2; Erbe Elektromedizin, Tuebingen, Germany). Check-up upper GI endoscopy was carried out 3 months after macroscopically complete ablation including biopsies from the neo-Z-line and the former BE segment, and recording of stricture formation. RESULTS From May 2011 to November 2012, a total of 60 patients (pt) were included in the study [55 pt male (92%); mean age 62 ± 9 years, range 42-79]. Ten patients were excluded from the study. In the remaining 50 pt, Hybrid-APC ablation and check-up endoscopy at 3 months were carried out. Forty-eight out of 50 pt (96%; ITT: 49/60, 82%) achieved macroscopically complete remission after a median of 3.5 APC sessions [SD 2.4; range 1-10]. Freedom from BE was histopathologically observed in 39/50 patients (78%). There was one treatment-related stricture (2%). Minor adverse events of Hybrid-APC were observed in 11 patients (22%). CONCLUSIONS According to this pilot series, Hybrid-APC was effective and safe for BE ablation in a tertiary referral center. The rate of stricture formation was only 2%. Further studies are required to confirm the present results. GERMAN CLINICAL TRIALS REGISTER DRKS00003369.
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Affiliation(s)
- Hendrik Manner
- Department of Internal Medicine II, HSK Hospital, Teaching Hospital of the University Medicine of Mainz, Ludwig-Erhard-Strasse 100, 65199, Wiesbaden, Germany.
| | - Andrea May
- Department of Internal Medicine, Sana Klinikum, Offenbach, Germany
| | - Ioanna Kouti
- Department of Internal Medicine II, HSK Hospital, Teaching Hospital of the University Medicine of Mainz, Ludwig-Erhard-Strasse 100, 65199, Wiesbaden, Germany
| | - Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, St. John of God Hospital, Regensburg, Germany
| | - Michael Vieth
- Institute of Pathology, Bayreuth Hospital, Bayreuth, Germany
| | - Christian Ell
- Department of Internal Medicine, Sana Klinikum, Offenbach, Germany
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Manner H, Neugebauer A, Scharpf M, Braun K, May A, Ell C, Fend F, Enderle MD. The tissue effect of argon-plasma coagulation with prior submucosal injection (Hybrid-APC) versus standard APC: A randomized ex-vivo study. United European Gastroenterol J 2014; 2:383-90. [PMID: 25360316 DOI: 10.1177/2050640614544315] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 05/25/2014] [Accepted: 06/29/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Thermal ablation for Barrett's oesophagus has widely been established in gastrointestinal endoscopy during the last decade. The mainly used methods of radiofrequency ablation (RFA) and argon-plasma coagulation (APC) carry a relevant risk of stricture formation of up to 5-15%. Newer ablation techniques that are able to overcome this disadvantage would therefore be desirable. The aim of the present study was to compare the depth of tissue injury of the new method of Hybrid-APC versus standard APC within a randomized study in a porcine oesophagus model. METHODS Using a total of eight explanted pig oesophagi, 48 oesophageal areas were ablated either by standard or Hybrid-APC (APC with prior submucosal fluid injection) using power settings of 50 and 70 W. The depth of tissue injury to the oesophageal wall was analysed macroscopically and histopathologically. RESULTS Using 50 W, mean coagulation depth was 937 ± 469 µm during standard APC, and 477 ± 271 µm during Hybrid-APC (p = 0.064). Using 70 W, coagulation depth was 1096 ± 320 µm (standard APC) and 468 ± 136 µm (Hybrid-APC; p = 0.003). During all settings, damage to the muscularis mucosae was observed. Using standard APC, damage to the submucosal layer was observed in 4/6 (50 W) and 6/6 cases (70 W). During Hybrid-APC, coagulation of the submucosal layer occurred in 2/6 (50 W) and 1/6 cases (70 W). The proper muscle layer was only damaged during conventional APC (50 W: 1/6; 70 W: 3/6). LIMITATIONS Ex-vivo animal study with limited number of cases. CONCLUSIONS Hybrid-APC reduces coagulation depth by half in comparison with standard APC, with no thermal injury to the proper muscle layer. It may therefore lead to a lower rate of stricture formation during clinical application.
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Affiliation(s)
- Hendrik Manner
- Department of Internal Medicine II, HSK Hospital, Wiesbaden; teaching hospital of the University Medicine of Mainz, Germany
| | | | - Marcus Scharpf
- Department of Pathology, University Hospital Tuebingen, Tuebingen, Germany
| | - Kirsten Braun
- Department of Internal Medicine II, HSK Hospital, Wiesbaden; teaching hospital of the University Medicine of Mainz, Germany
| | - Andrea May
- Department of Internal Medicine II, Sana Klinikum Offenbach, Offenbach, Germany
| | - Christian Ell
- Department of Internal Medicine II, Sana Klinikum Offenbach, Offenbach, Germany
| | - Falko Fend
- Department of Pathology, University Hospital Tuebingen, Tuebingen, Germany
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Keum B, Chun HJ, Seo YS, Kim YS, Jeen YT, Lee HS, Um SH, Kim CD, Ryu HS. Gastric intramural hematoma caused by argon plasma coagulation: treated with endoscopic incision and drainage (with videos). Gastrointest Endosc 2012; 75:918-9. [PMID: 21824610 DOI: 10.1016/j.gie.2011.04.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 04/25/2011] [Indexed: 02/08/2023]
Affiliation(s)
- Bora Keum
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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